Sex differences in the risk profiles for anastomotic leakage following surgery for rectal cancer

To clarify sex-specific differences in the risk profiles of anastomotic leakage (AL) after rectal cancer surgery, for which sex is widely recognized as an important risk factor.

This retrospective multicenter study included 1,854 patients (1,196 men and 658 women) who underwent rectal cancer surgery with anastomosis between 2015 and 2025 at our institution. Patients were stratified by sex, and risk factors for AL (grade ≥ B) were analyzed separately using logistic regression. Interaction analyses between sex and perioperative factors were also conducted.

AL occurred more frequently in men than in women (9.9% vs. 4.1%, respectively). In sex-stratified multivariate analyses, an anastomotic site ≤ 5 cm from the anal verge and transanal tube placement were identified as independent risk factors for AL in men, whereas minimally invasive surgery and the use of indocyanine green fluorescence imaging were associated with a reduced risk of AL. In women, a preoperative C-reactive protein-to-albumin ratio ≥ 0.07 and operative period were independent risk factors for AL. A significant interaction was observed between sex and low anastomosis rates.

Sex-specific differences in AL risk profiles have been suggested. Sex-specific risk assessment may contribute to more individualized strategies for diverting stoma decision-making.